J Epidemiol 2012;22(4):291-294

doi:10.2188/jea.JE20120079

Review Article

Social Epidemiology and Eastern Wisdom

Eric Brunner1, Ayako Hiyoshi1, Noriko Cable1, Kaori Honjo2, and Hiroyasu Iso3
1

Department of Epidemiology and Public Health, University College London, London, United Kingdom
Global Collaboration Center, Osaka University, Suita, Osaka, Japan
3
Osaka University, Suita, Osaka, Japan
2

Received April 10, 2012; accepted April 29, 2012; released online June 16, 2012

ABSTRACT
Social epidemiology is the eld of study that attempts to understand the social determinants of health and the
dynamics between societal settings and health. In the past 3 decades, large-scale studies in the West have
accumulated a range of measures and methodologies to pursue this goal. We would like to suggest that there may be
conceptual gaps in the science if Western research models are applied uncritically in East Asian studies of
socioeconomic, gender, and ethnic inequalities in health. On one hand, there are common concerns, including
population aging and gendered labor market participation. Further, international comparison must be built on shared
concepts such as socioeconomic stratication in market economies. On the other hand, some aspects of health, such
as common mental disorders, may have culturally specic manifestations that require development of perspectives
(and perhaps novel measures) in order to reveal Eastern specics. Exploring and debating commonalities and
differences in the determinants of health in Oriental and Occidental cultures could offer fresh inspiration and insight
for the next phase of social epidemiology in both regions.
Key words: social epidemiology; social science; social determinants of health; interdisciplinary research

Social epidemiology aims to understand the wider

determinants of health by using observational studies that
measure an enlarged set of exposures. In addition to the usual
downstream biomedical and behavioral risk factors, such
studies include measurements of upstream factors that can
be called causes of the causes.1 The growing interest in
population research on aging motivates studies of a spectrum
of novel age-related health outcomes, including vascular
aging, functioning, and functional limitation.2 This methodology has generated much evidence that socioeconomic
circumstances, living and working conditions, and social and
psychological factors are strong inuences on well-being
and health over the life course. In policy terms, the health
of a countrys population depends more on the ministries of
nance, housing, education, employment, and environment
than on the ministry of healthwhich would more accurately
be referred to as the ministry of illness.3,4 Social epidemiology
is science that supports the new public health movement5 and
encourages interdisciplinary approaches that move outside
the borders of conventional health promotion in search of
effective interventions.
Research design is guided by theoretical models of the
causes of the causes, and these models can be split into 2

contrasting groups. Materialist models emphasize income,

employment, housing, and other concrete factors. Their
strength is measurability. In contrast, psychosocial models
seek explanations for social differences in health and wellbeing by studying social, family, and working relationships
as well as beliefs and emotions. The strength of this level
of explanation is that it may lead to a detailed understanding
of the human experience of health and health inequality. Many
studies have explored whether the materialist or psychosocial
model is better at accounting for health inequalities within and
between populations, and most of these were published
between 1995 and 2005. The debate generated heat as well
as light. Both levels of explanation have intellectual and
empirical value, and their relative importance depends on the
health outcome and context in question.6,7
The example of social capital shows that the distinction
between materialist and psychosocial explanations can be
exaggerated. Social capital has been measured in different
studies by using several related components, including degree
of social cohesion, number of social ties, and level of social
trust.8 Both material and psychosocial advantage is gained
when social capital is relatively high: there may be exchange
of goods, loan schemes, and practical support of other kinds.

Address for correspondence. Eric J Brunner, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E
6BT (e-mail: e.brunner@ucl.ac.uk).
Copyright 2012 by the Japan Epidemiological Association

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Social Epidemiology in East Asia

There may also be emotional support at difcult times and

a sense of belonging that enhances health and quality of life.
Research in Japan has revealed such inter-relationships, eg,
greater area income inequality was linked to a lower level of
social trust and poorer self-rated health.9
Most evidence until now has been generated by research
groups in the United States, United Kingdom, and mainland
Europe, using Western population-scale studies.6,10,11 These
centers have contributed to graduate training for an increasing
number of groups of active East Asian researchers with
the skills and interests to study the important question
of social inequalities in health. It remains uncertain how
health inequalities are evolving across East Asia in this new
millennium.12,13 Japan remains at the top of the international
life expectancy league table. Perhaps it also maintains low
socioeconomic inequalities in health despite 2 decades of
economic stagnation and a rate of relative poverty that is now
similar to that in the United States and Mexico.14 If that were
the case, Japan would be a prime example of a rich country
maintaining excellent population health and managing to do
so in a sustainable way.
One challenge for research on the social and economic
determinants of health in East Asian countries is to understand
how their particular social systems and cultures support or
undermine health. In China, the prevalence of overweight
doubled in women and tripled in men between 1989 and 2006,
and there is evidence of emerging social inequality in this
important health determinant.15 In South Korea, low education
level has been linked with increased prevalence of metabolic
syndrome in women, and this inequality appears to be
growing in successive post-war birth cohorts.16 On the
other hand, Japans frugal food culture has so far largely
protected the population from the long march of the food
corporations,17,18 except in Okinawa, where the dietary pattern
is considerably westernized.19 The diversity in social trends
across East Asian countries suggests that comparative
studies would improve our understanding of how society
inuences population and individual health. In other words,
there appears to be potential to study the considerable
variation both in exposures and outcomes across the region.
However, researchers in the region must determine whether
there are important conceptual and methodological gaps in the
science that has been developed in the Western context.
Some social dynamics are common to East and
West. Increasing longevity brings the challenges of a
new demographic that is the consequence of life expectancy
at birth increasing at the rate of 3 months per year across
a large number of countries.20 Although a great majority
of the young old are able to live independently, surveys
show the proportion that needs some social care tends to
increase rapidly with age.21 The personal and collective costs
in health-related quality of life and economic burden will
be serious and difcult to manage if we ignore these at
least partially avoidable problems. There is a lot to learn

J Epidemiol 2012;22(4):291-294

about healthy aging from studies in East Asia, and much

would be relevant in the West.
As well as the shared concerns about the health of aging
societies, there is another fundamental shift that interests
social epidemiologists in the East and West, namely, the
continuing trend toward gender equality within the family and
in relation to the labor market. Age at rst marriage is
increasing and fertility is low, in part as a consequence of the
desire of young Japanese women to be free of family demands
at least until they have established a degree of economic and
personal autonomy.22 An undesirable effect in the Japanese
context is the high abortion rate: 22% of all pregnancies ended
in induced abortion in 2002.23,24 One explanation may be that
younger generations of women have a sense that the health
effects of marriage are different for men and for women, ie,
marital partnership results in fewer health benets for women,
whether they live in London or Osaka. The quality of the
relationship is probably what matters. Positive psychosocial
factors protect physical health, as shown in the inverse relation
between social support and cardiovascular disease riskmore
support, lower riskin the East and West.25
Some aspects of population health are socially and
culturally specic. This is most obvious in the tracking
of vital statistics such as birth and death rates by country
over time. Evidence on income inequality, life expectancy,
and other health outcomes between and within countries
suggests that distribution of material and other resources
across a given society is a key determinant of health.26,27
Social stratication is an important issue in this respect
because social epidemiology in part builds on the assumption
that market economies generate social class hierarchies
based on market or economic power, and that these are
comparable.2830 Further, a countrys system of social
stratication is fundamental in the assessment of health
inequalities and must be appropriately conceptualized and
measured to capture the particularities of the society of
interest. The labor market is a key dimension of social
structure, and social scientists have discussed over several
decades whether the Western concept of occupational social
class is applicable to Japan.31,32 A social classication based
on employment relations and status was found to detect
similar variation and function of social classes in Japan,
in comparison with Western countries.31,33 The research
community is increasingly interested in social stratication;
however, the EriksonGoldthorpe classicationthe theoretical basis of the UK National Statistics socioeconomic
classication (NS-SEC)has as yet been paid little
attention, and the measure has not been applied by social
epidemiologists in Japan to assess health inequalities.
With respect to social stratication, international
comparison must be built on shared concepts and methods.
In contrast, some health determinants would best be studied
with culturally specic tools.34,35 Mental health is a particularly important dimension of health. The conventional,

Brunner E, et al.

Western approach has proved to have weaknesses and thus

a new understanding would be welcomed. Medication has
long been the rst-line treatment for depression in Europe
and North America. However, it has been suspected for
many years that drug treatment does not lead to improved
outcomes except among those suffering from major and
chronic depression. A recent expert review by the UK
National Institute of Clinical Research conrmed this view
and concluded that medication should no longer be the
primary treatment for depression in the National Health
Service (NHS). The headline advice in the detailed 2010
report tells doctors: Do not use antidepressants routinely to
treat persistent sub-threshold depressive symptoms or mild
depression because the riskbenet ratio is poor.36
Research in East Asia may help to solve the widespread
problem of chronic poor psychological health among adults. A
Japanese study using the Beck Depression Inventory (BDI),
which was developed in the United States, found that the
BDI had similar validity in terms of factor structure in the
United States and Japan, which implies that depression is a
universal construct with universal symptoms and solutions.37
However, there is also a view that depressive symptoms
may differ between Western and Eastern societies, particularly
in their somatic manifestations (Ichiro Kawachi, personal
communication). Somatic symptoms measured in the BDI
are loss of energy, sleep problems, irritability, appetite
problems, lack of concentration, tiredness, and sexual
disinterest. Draguns mentions the greater separation between
soma and psyche in Western culture.34 Related to this, there
may be a lower level of cultural acceptance of depression
as a largely mental disorder in East Asia.
These hypotheses suggest a need for studies using
instruments developed by researchers who appreciate
Eastern cultures, so as to inspire fresh thinking in the eld
of mental health. It could be that a difference in the pattern
of depressive symptoms between East and Westwhich is
not evident using the BDImay be detectable using an
instrument developed in the East. East Asian practices,
perhaps with emphasis on social support networks, may
work more effectively with mental distress than current
antidepressant medications.38,39
If it is accepted that there might be culturally specic
aspects of the social determinants of health, then it may
be valuable to develop new constructs for use in social
epidemiology. Such work would complement the extension
of established methods, including measurement of socioeconomic position, to facilitate comparison of health
inequalities in East Asian countries. It is likely that existing
and new approaches are neededcombining development of
newly validated psychosocial measures with validation of
existing measures in China, Korea, Japan, and other East
Asian countriesto understand relationships between social
determinants such as strong community structures and levels
of well-being in their respective populations.

293

Models of population health that are rooted in the cultures

of East Asian countries may improve on models developed
in the United Kingdom, for example, in their explanatory
power for social inequalities in health outcomes. This is not
to suggest that there is some mystical Oriental secret to health
and longevity, but rather that the whole picture of EastWest
differences in social inequalities in health will not be captured
if we favor Occidental constructs of psychosocial factors,
well-being, and social position when such constructs are
subject to major cultural and philosophical inuences.
Drawing on existing research models and methods is
practical and has been productive during the rst phase of
social epidemiology in East Asia. Development of newly
validated measures of social determinants inspired by East
Asian researchers will surely be important for East and West
in the second phase.

ACKNOWLEDGMENTS
Conicts of interest: None declared.

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